HAIR LOSS WORKSHEET
NAME: DATE:
1. When did the hair loss start? 2. What areas on the scalp/body are you loosing hair?
3. Is the loss: Constant Worsening Improving Stable
4. Do you lose more than 100 hairs a day? Yes No 5. Is the hair coming out at the roots or breaking off? 6. Current hair care: Chemical treatments to the hair? Yes No Last treatment: How often: Type of chemicals used: Did it affect hair loss: How often do you shampoo you hair? Which Shampoo: What conditioner is used? Please circle any current hair care:
Blow dry hair Airdryhair Curlingiron Wetsethair Hotcombs Hotrollers
Elastic hair items Head bands Hair weaves Hair pieces “Tight” styles (ex: pony tail, bun, braids)
7. Any previous history of hair loss? Yes No Was it ever investigated? 8. Is your scalp itchy, tender, painful, sore, or sensitive? 9. Do you pull or twist your hair? Yes No 10. Have you noticed any increase in hair growth on the face, chest, or legs? 11. Have you noticed any increase in acne or pimples? 12. General Health History- Please circle all that apply Increased Fatigue Weight loss Brittle nails Increased stress Changes in menstrual period Recent surgery Recent severe illness Lupus
Anemia (low iron) Thyroid problems Diabetes Vitiligo (loss of color) High Blood Pressure Kidney problems Liver problems 13. Any recent pregnancies/ hormone/ birth control pills therapy before the hair loss? Yes No
14. Are your menses regular? Yes No Any history of hormone problems? Yes No 15. Is their any Family History of hair loss/ early balding? Yes No Who? 16. Any new medication that coincided with the hair loss? 17. Does anything make the hair loss: worse? better?
Review by:
East Valley Dermatology Center, 1100 S. Dobson Rd, Suite 223, Chandler, AZ 85286, (480) 821-8888